01-009 General Inpatient Hospice Notification of Medical Review

Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for general inpatient hospice billed on dates of service from January 1, 2017 through December 31, 2017. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter and resources providers/suppliers may wish to consult when submitting claims.

Background

The Office of Inspector General (OIG), under report OEI-02-10-00491: Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care, dated March 2016, found that hospices commonly billed for General Inpatient Care (GIP) when the beneficiary did not have uncontrolled pain or unmanaged symptoms. According to the report, Hospices inappropriately billed Medicare over $250 million for the GIP level of care.

Reason for Review

In response to the OIG report, the CMS tasked Noridian, as the SMRC, to conduct medical review. The SMRC will perform review activities on GIP hospice claims to ensure the services were paid appropriately.

Claim Sample Detail

HCPCS
  • Q5004: Skilled Nursing Facility (SNF)
  • Q5005: Inpatient hospital
  • Q5006: Inpatient hospice facility

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Notice of Election (NOE) for Hospice effective for the date of service (DOS) under review.
  2. Certification(s) of Terminal Illness (CTI) that cover the DOS under review.
  3. Face-to-Face Encounter Attestation statements as applicable to the certification period(s) during which the GIP care was provided.
  4. Documentation to support the GIP stay for pain control and/or symptom management indicating the interventions performed could not be feasibly provided in any other setting for the DOS under review. This may include, but is not limited to, the following:
    1. Hospice Plan of Care (POC) covering the GIP stay supporting the change in LOC including dates, reason for GIP, interventions, beneficiary’s response and collaboration between the hospice and hospital teams.
    2. Clinical documentation to include, but not limited to, admission history and physical, progress notes, consultation notes, nursing assessments, treatment records, wound care documentation, medication administration records and discharge summary.
    3. Hospice team documentation to include, but not limited to, visits, assessments and discharge planning for the DOS under review.
  5. Copies of any written notices provided to the patient. For example, Advance Beneficiary Notice (ABN) of Noncoverage)
  6. Valid clinician signatures.
    1. Signature Attestations and Signature Logs should be submitted when Physician or Clinician signatures are illegible.

References/Resources

  • Social Security Act (SSA) Title XVIII, Sections 1812(a)(4), (a)(5), (d)(1). Scope of Benefits
  • Social Security Act (SSA) Title XVIII, Section 1814(a)(7). Conditions of and Limitations on Payment for Services – Requirement of Requests and Certifications
  • Social Security Act (SSA) Title XVIII, Sections 1815(a), (e)(2)(D). Payment to Providers of Services
  • Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits
  • Social Security Act (SSA) Title XVIII, Section 1861(dd). Definitions of Services, Institutions, Etc. – Hospice Care
  • Social Security Act (SSA) Title XVIII, Section 1862 (a)(1)(c). Exclusions from Coverage and Medicare as Secondary Payer
  • Social Security Act (SSA) Title XVIII, Sections 1879(a)(1), (g)(2). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
  • Code of Federal Regulations Title 42, Section 424.5(a)(6). Conditions for Medicare Payment – Basic Conditions, Sufficient Information
  • Code of Federal Regulations Title 42, Section 418, Subpart A. General Provisions and Definitions
  • Code of Federal Regulations Title 42, Section 418, Subpart B. Eligibility, Election and Duration of Benefits
  • Code of Federal Regulations Title 42, Section 418, Subpart F. Covered Services
  • Code of Federal Regulations Title 42, Section 418, Subpart G. Payment for Hospice Care
  • Medicare General Information, Eligibility and Entitlement Manual, Pub. No. 100-01, Chapter 4, Section 60. Certification and Recertification by Physicians for Hospice Care
  • Medicare General Information, Eligibility and Entitlement Manual, Pub. No. 100-01, Chapter 5, Section 60. Hospice Defined
  • Medicare Benefit Policy Manual (MBPM), Pub. No. 100-02, Chapter 9, Section 10. Requirements—General
  • Medicare Benefit Policy Manual (MBPM), Pub. No. 100-02, Chapter 9, Section 20. Certification and Election Requirements
  • Medicare Benefit Policy Manual (MBPM), Pub. No. 100-02, Chapter 9, Section 40. Benefit Coverage
  • Medicare Claims Processing Manual (MCPM), Pub. No. 100-04, Chapter 11. Processing Hospice Claims
  • Medicare Claims Processing Manual (MCPM), Pub. No. 100-04, Chapter 30, Section 50. Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN)
  • Medicare Program Integrity Manual (MPIM), Pub. No. 100-08, Chapter 3, Section 3.3.2.4. Signature Requirements

Last Updated Feb 11, 2019